Sometimes it is helpful to combine different treatments to achieve a better result, either at the same visit or subsequently.

It stands to reason that when one has an injury more than one structure may be affected- muscles, fascia, ligaments, tendons etc. What is not as well known is that cutaneous nerves become sensitized and may perpetuate pain through the release of specific chemicals (such as CGRP). Different structures require different approaches.

We may have already treated myofascial pain with the pain neutralization technique (PNT) or trigger point injections but the patient may have some residual symptoms. We often combine perineural injections with prolotherapy or may combine prolotherapy with PRP. Sometimes we use acupuncture or acupressure to calm symptoms of anxiety or light-headedness if a person is apprehensive. PNT can substantially reduce the number of trigger point injections needed.

One example: A lady was referred for acupuncture for treatment of longstanding shoulder and upper back pain which was interfering with her work. She was very keen to have this fixed but was so apprehensive about the needles that she broke out in a sweat (quite unnecessarily) before she could be examined. Instead of tackling the painful area directly she was initially asked to lie down on the exam table and four thin sterile acupuncture needles were gently inserted into peripheral points in her hands and feet which are known to have pain-modifying effects and which moderate the "fight and flight" response. After resting quietly for 20 minutes she was feeling much better (people often find acupuncture and acupressure quite relaxing or soporific). Then all but one of the tender points in her shoulder, arm and upper back were released with PNT using finger pressure only (no needles needed!). Only one resistant point on the side of her upper arm was still tender (what the Chinese would call an ah shi point); this was treated with an acupuncture needle briefly. When seen in follow-up she remained pain-free and able to work without discomfort.

Another example: A lady was seen for chronic pain in her neck, shoulders, back, thigh and hip which had persisted following a motor vehicle collision. Her X-rays were normal; all her pain was "soft-tissue" but her function was limited. At the initial visit she was found to have very limited range of movement of her one shoulder with multiple tender points around the neck, shoulder and upper back. She also had limited movement of her lower back and one hip because of pain. PNT released her shoulder and neck pain the first visit and she regained full range of movement within a few minutes. On a few subsequent visits some recurrent tender points were released. PNT also released painful areas in her abdominal muscles which can cause referred pain to the back. Her back muscles and thigh needed trigger point injections and some of her hip pain responded to perineural injections. Obviously, these methods will not correct major structural abnormalities but because pain reduces function by inhibiting muscle movement, when the pain is relieved function is often restored.

Trigger points are tender taut bands in muscle or fascia which, when pressed, often elicit a "jump" or "ouch" response from the patient, and may produce a predictable referred pain pattern to other areas nearby. Some people call them "palpable pain points". They may be active (i.e. produce pain even when not pressed) or latent, (producing tenderness when pressed but not otherwise). They may be primary - the original site of the injury, or secondary , due to the muscle having to over-work because of lax ligaments, for instance. There is a tendency for new tender points to form in the same muscle or neighbouring muscles.

Trigger point pain may mimic other conditions because of referred pain. Some examples: Trigger points in the sternocleidomastoid muscle (the long strap-like muscle that stretches from behind your ear down to the collar bone and turns your head to the other side) can cause pain in the upper teeth leading to unnecessary dental work being done. Trigger points in the pectoralis major can mimic a heart attack or produce breast pain.

Trigger points can form as a result of injury (such as a muscle strain or fall), or form over-use, posture or poor ergonomics, or when the muscle has to compensate for other structures which are not functioning adequately.

Trigger points (known as ah shi points) were treated with acupuncture long before western physicians began treating them in the 1940s. Drs. Travell and Simons produced a two volume encyclopedic description of different muscles and their pain patterns and how to treat them with a combination of injections, stretches and cool sprays. Most trigger point charts, pictures and books are based to a greater or lesser degree on those two volumes.

Trigger Point Treatment Options:

1. ischemic compression - this involves identifying a tender point, pressing on it with a thumb, finger, ball or other object (such as a theracane) firmly enough to cause discomfort but not severe pain. One then stretches the muscle along its long axis, takes in a deep breath and presses a little firmer. An excellent explanation of this technique can be found on Dr Kuttner's website. This is not the method we use but it is effective and can be a useful form of self-therapy. Dr Kuttner's site is very informative and he has inexpensive resources available there.

2. Various myofascial release techniques have been used by physiotherapists and massage therapists and are often effective but may aggravate the pain if administered too vigorously, or if the pain is due to inflamed sensory nerves rather than primarily a muscular problem.

3. Our preferred non-needle technique is a group of simple, painless, and safe procedures collectively known as the "Pain Neutralization Technique", which, when effective, works nearly instantly. 4. Acupuncture or "dry-needling" has been used for centuries to treat trigger points. Modern versions - using a very fine, single-use, pre-packaged, sterile, disposable, solid (not hypodermic) acupuncture needle - include Dr. Chan Gunn's Intramuscular Stimulation (IMS) and Dr Cynthia Gokavi's adaptation, the Gokavi Transverse Technique. IMS or dry-needling are often offered by physiotherapists and pain clinics and do not involve any medications. 5.Trigger points can also be injected with a hypodermic needle and syringe. With injections one has both the direct needle effect and the ingredient effect. The needle itself does much of the work in releasing the tight band. Drs. Travell and Simon pioneered the use of local anesthetic injections into trigger points using Procaine. Today Lidocaine is usually the local anesthetic of choice; some physicians mix this with longer-acting local anesthetic such as Bupivicaine (Marcaine) and may add some steroid (cortisone-like medication). There is no evidence that steroids are helpful for this and may be harmful. Longer-acting anaesthetics are said to reduce the post-injection soreness from the needle which some people feel later, but carry greater risk if used in excess doses, or if they get into the bloodstream too quickly. Some alternative practitioners add herbs, vitamins and homeopathic remedies to their injections but we do not advocate this. Some physicians use normal saline without anaesthetic for trigger point injections. This avoids the rare risks associated with the medications but may leave a little more soreness the next day. Dr Greg Siren (at the Myo Clinic and Changepain) uses this method very effectively and has generously taught this to other physicians in BC.

A study was published in Korea in 1997 comparing three groups of patients with trigger point injections, one group with normal saline, one group with local anesthetic, and another group with 5% dextrose (D5W). Each method was effective but, of these, the local anesthetic group did better than saline, and D5W performed the best of the three. This is possibly because of the known benefit of dextrose in relieving neurogenic pain. This is only one study and if repeated elsewhere might produce a different outcome.

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